- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $794.33 / $2,187.76
| Professional | | $407.38 | $794.33 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $5,754.40
| Facility | | $4,677.35 | $4,677.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $602.56 / $812.83
| Professional | | $338.84 | $602.56 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $741.31 / $1,479.11
| Professional | | $380.19 | $741.31 | $1,479.11 |